"Medicine is a social science, and politics is nothing else but medicine on a large scale"—Rudolf Virchow

February 08, 2018

Around 10,000 migrants and refugees are living in inhumane conditions in Italy because of inadequate reception policies, says Médecins Sans Frontières (MSF) in a report released today.

Refugees and migrants live in informal settlements and have limited access to basic services. MSF calls on national and local authorities to ensure that all migrants and refugees in Italy have access to medical care, shelter, food and clean water for the entire period that they are in Italy, regardless of their legal status.

The report ‘Out of Sight’, is based on MSF monitoring of several informal settlements, such as slums, squats and occupied buildings in Italy during 2016 and 2017. The first edition was published two years ago.

“Two years after it was first published, the ‘Out of Sight’ report is still a sad survey of vulnerability and marginalisation. It describes a situation in which thousands of people who are entitled to refuge and protection do not even have a decent shelter to sleep in, enough food, or access to a doctor,” says MSF advocacy officer Giuseppe De Mola.

“Refugees and migrants are living on the margins of society because of an inadequate reception system and harmful border policies. What’s more, policies designed to foster social inclusion of migrants and refugees at the national, regional and local level are poorly implemented.”

The report shows that refugees and migrants are living in smaller groups compared to 2016 because evictions have broken up the informal settlements in which they were staying. With no alternative housing on offer to them after they are evicted, refugees and migrants are forced to seek shelter in places that are hidden from the rest of society, like abandoned buildings.

The refugee and migrant population is now more widely spread out. This, combined with language and administrative barriers, makes it extremely difficult for them to access social services and healthcare, as well as basics like clean water, food and electricity.

Local volunteers frequently provide assistance and access to these services to migrants and refugees outside the governmental reception system. These volunteers are often in turn put under huge pressure by national and local authorities, who in some cases have even brought legal proceedings against them.

MSF has also carried out a second study, ‘Harmful Borders', on the situation in Ventimiglia, an Italian town on the border with France. The study shows that despite the Schengen agreement still being formally in place, migrants are blocked at these borders, living in informal settlements with limited access to essentials and healthcare. They are regularly pushed back from the Italian-French border: of the 287 people interviewed for MSF’s survey almost one in four migrants say they have experienced episodes of violence at the border. In most cases, this violence was allegedly perpetrated by Italian and French border authorities.

The study records more than 20 deaths in the past two years resulting from people trying to cross restricted borders into France, Austria or Switzerland.

February 02, 2018

At least 90 migrants are reported to have drowned, when a boat capsized off the coast of Libya this morning (02/02). According to IOM Libya’s Olivia Headon, 10 bodies are reported to have washed up on Libyan shores – two Libyans and eight Pakistani nationals. Two survivors are reported to have swam to shore, while another was rescued by a fishing boat, Headon said. IOM is working to get more details of the tragedy and to see how best to assist survivors, she continued.

"According to IOM records, some 29 Libyans were rescued or intercepted in all of 2017, but we estimate the true figure to be much higher,” said Headon.

In 2017, the 3,138 Pakistani migrants arriving by sea to Italy from Libya were 13th in the overall list of migrant arrivals (119,369). This year though, they already are the third highest nationality so far, with an estimated 240 reaching Italy in January. In comparison, only nine Pakistanis arrived in Italy by sea in January 2017.

According to IOM’s Missing Migrants project (MMP), there were no confirmed deaths of Pakistani or Libyan nationals in the Mediterranean in 2017. In 2016, MMP recorded that 8 Pakistani nationals went missing in the Eastern Mediterranean in a shipwreck on 14 March 2016 near Kos, Greece.

This latest tragedy comes as IOM, the UN Migration Agency, reports that 6,624 migrants and refugees had entered Europe by sea through 28 January. This compares with 5,983 coming ashore during a similar period in 2017. Italy accounts for approximately 64 per cent of the total, with the remainder split between Spain (19 per cent) and Greece (16 per cent).

The risk of tuberculosis outbreaks among people fleeing hardship for refuge in Europe is heightened. We describe the cross-border European response to an outbreak of multidrug-resistant tuberculosis among patients from the Horn of Africa and Sudan.

Methods

On April 29 and May 30, 2016, the Swiss and German National Mycobacterial Reference Laboratories independently triggered an outbreak investigation after four patients were diagnosed with multidrug-resistant tuberculosis. In this molecular epidemiological study, we prospectively defined outbreak cases with 24-locus mycobacterial interspersed repetitive unit-variable number tandem repeat (MIRU-VNTR) profiles; phenotypic resistance to isoniazid, rifampicin, ethambutol, pyrazinamide, and capreomycin; and corresponding drug resistance mutations. We whole-genome sequenced all Mycobacterium tuberculosis isolates and clustered them using a threshold of five single nucleotide polymorphisms (SNPs). We collated epidemiological data from host countries from the European Centre for Disease Prevention and Control.

Findings

Between Feb 12, 2016, and April 19, 2017, 29 patients were diagnosed with multidrug-resistant tuberculosis in seven European countries. All originated from the Horn of Africa or Sudan, with all isolates two SNPs or fewer apart. 22 (76%) patients reported their travel routes, with clear spatiotemporal overlap between routes. We identified a further 29 MIRU-VNTR-linked cases from the Horn of Africa that predated the outbreak, but all were more than five SNPs from the outbreak. However all 58 isolates shared a capreomycin resistance-associated tlyA mutation.

Interpretation

Our data suggest that source cases are linked to an M tuberculosis clone circulating in northern Somalia or Djibouti and that transmission probably occurred en route before arrival in Europe. We hypothesise that the shared mutation of tlyA is a drug resistance mutation and phylogenetic marker, the first of its kind in M tuberculosis sensu stricto.

The Trump administration has canceled the provisional residency permits of about 200,000 Salvadorans who have lived in the country since at least 2001, leaving them vulnerable to deportation, according a copy of a Department of Homeland Security announcement sent to lawmakers Monday.

The administration will notify the Salvadorans that they have until Sept. 9, 2019, to leave the United States or find a way to obtain legal residency.

The Salvadorans were granted what is known as Temporary Protected Status, or TPS, after earthquakes devastated their country in 2001.

According to the DHS statement, Homeland Security Secretary Kirstjen Nielsen determined that conditions in El Salvador have improved significantly since then, ending the original justification for the deportation protection.

“Only Congress can legislate a permanent solution addressing the lack of an enduring lawful immigration status of those currently protected by TPS who have lived and worked in the United States for many years,” the announcement states. “The 18-month delayed termination will allow Congress time to craft a potential legislative solution.”

Monday’s decision was not a surprise, and is part of the White House’s broader goal of reducing legal immigration to the United States and intensifying efforts to expel those who arrived illegally.

The El Salvador TPS decision was the most momentous for the administration to make, because of the sheer number of people affected. The 200,000 are the parents of an estimated 190,000 U.S.-born children, according to recent studies, and about one-third are homeowners.

But Trump administration officials have consistently signaled that they viewed the TPS program as an example of American immigration policy gone awry, noting that when Congress created the TPS designation in 1990, its purpose was to provide “temporary” protection from deportation.

In November, DHS ended TPS for 60,000 Haitians who arrived after a 2010 earthquake, and for 2,500 Nicaraguan migrants protected after Hurricane Mitch in 1998.

So close to 400,000 persons (almost half of them American citizens) will be forced to resettle in a poor and violent country. This is indeed politics as the practice of medicine on a large scale.

WHO's Country Page for El Salvador tells us that the country has about 6.1 million people. Babies born there in 2015 have a life expectancy of 69 for males and 78 for females. The probability of dying between the ages of 15 and 60, per 1,000 population is 262 for males and 105 for females. The country spends US$565 per capita on healthcare.

Go to WHO's World Health Statistics 2017 and you'll find more worrying news: 54 maternal deaths per 100,000; 16.8 deaths per 1,000 children under five; 43 TB cases per 100,000; 24.1 health professionals per 100,000 (the US has 117.8); a stunting rate of 13.6% among children under five; and a homicide rate of 63.2 per 100,000—exceeded in the Americas only by Honduras's 85.7.

Now imagine a country of 6.1 million absorbing 390,000 newcomers—half of them speaking little or no Spanish—who will need health, education, shelter, and work.

Being sensible people, the Salvadoran-American deportees will not likely stay in El Salvador. First, they'll fight this in the US courts. If they lose, they'll go underground, or head for Canada. Those who are deported will head north again, perhaps to Mexico but more likely back to the US. They will likely find travelling companions in deported Haitians and Nicaraguans.

Along the way, the deportees will stress the health systems of Central America and Mexico, while offering dazzling new opportunities for human traffickers, crooked cops and corrupt politicians. It will be yet another chronicle of deaths (and ruined lives) foretold.

January 05, 2018

In France, the public health insurance system has a principle of universality. However, refusal to provide care by health-care professionals has recently emerged as an issue. People living with HIV and vulnerable populations have an increased risk of being denied care.

The ANRS-PARCOURS study analyses how health trajectories and social and migratory paths are interlaced for migrants from sub-Saharan Africa living in France. It is a life-event survey that was done in 2012–13 in health-care facilities in the Paris area, among sub-Saharan migrants recruited in primary care centres (n=760; reference group) and in HIV care centres (n=922; HIV group). A trained interviewer administered a face-to-face, standardised, life-event history questionnaire to each participant.

When participants answered that they had been denied care, they were asked about the reason for the denial of care. These reasons were categorised by the investigators and then analysed. We weighted the percentage of patients to take into account the study design. When participants were asked about their experiences with refusal of health-care since their arrival in France and about the reasons underlying refusal, refusal of care was reported more often in the HIV group (119 [12%] of 922 participants) than in the reference group (59 [6%] of 760 participants, p=0·0006; appendix).

Denial of care appeared to be more frequent at general practices (6·4% for the HIV group and and 3·2% for the reference group) than at hospitals (3·0% and 1·4%) and pharmacies (5·2% and 2·8%; appendix). The main reasons for refusal of care were refusal of the specific health insurance coverage for poor people and undocumented migrants (28 [40%] of 59 participants in the reference group and 36 [32%] of 119 participants in the HIV group), HIV status (33 [29%] in the HIV group), and being uninsured (16 [26%] in the reference group and 34 [25%] in the HIV group).

In France, two schemes—the Universal Health Insurance Coverage and the State Medical Assistance (created in 1999)—are available for vulnerable populations and for undocumented migrants who were previously excluded from the health insurance system. These two schemes ensure free health care for these populations.

Nevertheless, some health professionals deny the beneficiaries. The reasons identified for denying care to these patients were mainly about delays in payments and minimal payments, discriminatory reasons and fear of contracting HIV have also been reported.

As our survey suggests, refusals to provide health care are too frequent. For migrants who have often encountered many bureaucratic obstacles to benefit from French health insurance dedicated to the poor or the undocumented, being denied access to care by health-care professionals or services is unlawful and should not be tolerated. Refusal of care for migrants with and without HIV needs to be addressed to improve equity in health-care systems. Policymakers, insurance bodies, and health councils must act.

IOM, the UN Migration Agency, is scaling up efforts to evacuate migrants from Libya and help them reach their home countries under the Voluntary Humanitarian Return Assistance (VHR). In addition to the Nigeria and Guinea flights, on Thursday (28/12), another charter flight carrying 170 returnees landed in Bamako, Mali.

In the wake of shocking reports about rampant migrant abuse and squalid and overcrowded conditions across multiple detention centers in Libya, talks at the AU-EU Summit in Abidjan, Côte d’Ivoire from to 29 to 30 November, led to a major revamping of measures to tackle smuggling and mistreatment of migrants on the central Mediterranean migration route, which has claimed 2,833 migrant lives to drowning this year alone. Leaders from both regions committed to work together to end the inhumane treatment of migrants and refugees in Libya. Another issue discussed at the summit was how to address jointly the root causes of irregular migration.

So far in 2017, 18,803 returnees have been assisted under the VHR programme. That number is expected to reach 19,000 migrants by the end of this month. Close to 6,000 migrants have returned to their countries of origin since the evacuation phase started on 28 November.

At the Gbessia International Airport in Conakry, the returnees were welcomed by representatives of the ministries of foreign affairs, youth and youth employment, and social affairs and protection.

Among the Guinean returnees was a young man named Moussa. “Look at this, ” said Moussa, showing a bullet scar on his calf. “Someone fired at me while I was running in the desert, because it was impossible for me to be caught, I was running so fast.”

“I came to welcome my friends, my little brothers,” said Kabinet, a returnee who had spent two years in prison in Libya, where he was also subjected to violence.

“I’m a sort of big brother. That’s why I thought it would be good for me to see [the returnees] when they got off the plane,” he explained. “In Libya, I worked under harsh conditions in a factory. We had different dreams, to play football in Europe, to take care of our families. We now hope to open a small cleaning business. There seems to be another desert to cross but we will give it all.”

Upon arrival to Conakry, the returnees received travel kits of toiletries and snacks; the most vulnerable migrants received psychosocial support, as well. All migrants also received a “pocket money” allowance of €50 to cover their immediate needs such as transportation, clothing and housing once they arrived. Each was transported to a local transit center to spend the night (upon request), receiving additional meals in the process.

IOM has identified 432,574 migrants in Libya, mainly in the Tripoli, Misrata and Almargeb regions, and estimates the number of migrants to be more than 700,000 and up to 1 million.

For the past year, the return of migrants has been funded by the European Union Emergency Trust Fund for Africa (EUTF), the United Kingdom, Italy, the Netherlands, Norway, The UN’s Central Emergency.

3,172 refugees and asylum-seekers have been forcibly transferred by Australia to ‘offshore processing’ facilities in Papua New Guinea and Nauru since the introduction of the current policy in 2013.1 Of these, some 800 remain in Papua New Guinea.

Following the Australia-United States relocation arrangement, UNHCR has referred more than 1,200 refugees to the United States of America since December 2016. Another 500 people still require a review of their refugee status determination process by authorities in Papua New Guinea and Nauru, under the Australian arrangement.

Long-term solutions remain needed for all people transferred by Australia to Papua New Guinea and Nauru. Neither Papua New Guinea nor Nauru are appropriate places for local integration for the majority of refugees and asylum-seekers, particularly given their acute needs as a result of prolonged detention and harsh conditions.

An estimated 258 million people are international migrants, a figure that has surged by a half since the turn of the century, the United Nations said on Monday.

One in ten of those people is a refugee or asylum seeker, the U.N. said in a report on migration trends and developments released to coincide with International Migrants Day.

Globally, 3.4 percent of the population consists of international migrants, meaning someone who lives in a country other than the country where they were born, it said.

"Reliable data and evidence are critical to combat misperceptions about migration and to inform migration policies," Liu Zhenmin, U.N. Under-Secretary-General for Economic and Social Affairs, said in a statement.

The rights of migrants and the need for safe, well-managed migration policies are included in the set of Sustainable Development Goals (SDGs) adopted unanimously by the U.N. member nations in 2015, and the U.N is planning an international conference on migration late next year.

Other figures showed that migration contributed 42 percent of the population growth in Northern America between 2000 and 2015, and that the population in Europe would have declined during that time period without migration.

More than 110 suspected cases, including 6 deaths, have been clinically diagnosed by health partners, including Médecins Sans Frontières (MSF) and the International Federation of the Red Cross (IFRC).

"These cases could be just the tip of the iceberg. This is an extremely vulnerable population with low vaccination coverage, living in conditions that could be a breeding ground for infectious diseases like cholera, measles, rubella, and diphtheria," said Dr Navaratnasamy Paranietharan, WHO Representative to Bangladesh.

"This is why we have protected more than 700,000 people with the oral cholera vaccine, as well as more than 350,000 children with measles-rubella vaccine in a campaign that ended yesterday. Now we have to deal with diphtheria."

Since August 2017, more than 624,000 people fleeing violence in neighbouring Myanmar have gathered in densely populated temporary settlements with poor access to clean water, sanitation and health services – and the numbers continue to swell.

WHO is working with the Bangladesh Ministry of Health and Family Welfare, UNICEF and partners to contain the spread of the highly infectious respiratory disease through effective treatment and adequate prevention.

Together, they are supporting patient diagnosis and treatment, ensuring adequate supplies of medicines, and preparing a vaccination campaign targeting all children up to 6 years with pentavalent (DPT-HepB-Hib) and pneumococcal vaccines, which protect against diphtheria and other diseases. Training is already underway for vaccinators.

WHO has procured an initial 1,000 vials of diphtheria antitoxins that are due to arrive in Bangladesh by the weekend. Combined with antibiotics, the antitoxins can save the lives of people already infected with diphtheria, by neutralizing the toxins produced by the deadly bacteria.

"We are working with partners to ensure that clinical guidance is available to health workers, and that there are enough beds and medicines for those who get sick. But the only way to control this outbreak is to protect people, particularly children, through vaccination," said Dr Paranietharan.

November 28, 2017

On Oct 31, 2017, the Governments of Australia and Papua New Guinea ended support for the Manus Island Regional Processing Centre, an Australian immigration detention facility on Manus Island, Papua New Guinea.

Instead, currently incomplete and substandard facilities without adequate service provision have been hastily constructed to accommodate people. 379 refugees and asylum seekers refused to leave the centre stating fears for their security. They managed to survive for several weeks with no provision of food and water or electricity and in poor hygienic circumstances. However, on Nov 23–24, 2017, the Papua New Guinea police went into the centre moving people out on buses to these incomplete facilities.

The physical and mental health of these people is precarious.4 Since 2013, an estimated 3000 refugees and asylum seekers have been forcibly transferred by Australia to so-called offshore facilities in Papua New Guinea and Nauru where asylum claims of people who entered Australian territories by boat are processed. Around 1200 refugees and asylum seekers remain in Nauru and 900 in Papua New Guinea.

The office of the United Nations High Commissioner for Refugees (UNHCR) has repeatedly spoken out against this practice that does not provide international protection to those who need it but is driven by the desire to deter future asylum seekers and deny any possibility of settlement in Australia. At the former detention facilities people had been placed for indefinite periods without external freedom of movement and no prospects for resettlement in Australia or family reunification.

Such an environment is wholly inappropriate for the housing of refugees and asylum seekers, violates their basic rights, and has associated social and health costs. The punitive conditions and absence of realistic long-term solutions cause harm to asylum seekers, particularly related to their mental health.

During a monitoring visit by UNHCR to Manus Island in 2016, one of us (SS) with other medical colleagues held individual interviews with 181 of the detainees in the Manus Island Regional Processing Centre. Most (90%) of the detainees met criteria for severe mental health conditions such as major depression, severe anxiety disorder, and probable post-traumatic stress disorder. Diagnoses could not be confirmed against Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) or International Classification of Diseases, Tenth Revision (ICD-10) criteria and therefore cannot be seen as evidence of the presence of a true mental disorder but indicate high rates of psychological distress. Most interviewees (71%) had experienced torture or traumatic events before seeking asylum and most reported not having symptoms of mental disorders before detention.

The UNHCR team concluded that the lengthy, arbitrary, and indefinite nature of immigration detention on Manus Island, together with hopelessness in the absence of durable settlement options, had corroded the resilience of the detainees, and made them vulnerable to mental illness.